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Sunday, December 15, 2013

I don’t know whether you had a chance to watch the musical Fiddler on the Roof. Tevye, the main character of the musical, tries to explain tradition in the opening song. And so it goes, “You may ask: How did this tradition get started? I’ll tell you. I don’t know. But it’s a tradition. And because of our traditions everyone of us knows who he is, and what God expects him to do.”

Traditions -- we come across them all the time, those time-honoured arguments for continuing along a well-worn path. Catholic bishops in the United States tell us that euthanasia is wrong, because, among other reasons, it violates medical tradition. Even the Canadian Medical Association, in a booklet published on the issue in 1993 traces some beliefs that are held strongly by some medical doctors on euthanasia back to tradition. It doesn’t take opponents of assisted dying very long to hark back to the unfortunate Hippocratic Oath that most medical school graduates are forced to take in grand ceremonies in some form or shape. These ceremonies are really quasi-religious activities where senior doctors (typically the medical schools’ professors) demonstrate their faith in their students’ ability to carry on the medical tradition. In turn, and because it is tradition, the students make wild and quite frankly oftentimes silly public promises including not to participate in what we would describe today as surgery.

Not a big surprise really, considering that this Oath got started some 2,500 years ago, likely by a Pythagorean cult. Since then the oath has been issued in revised and modernised versions by various medical associations and other interested groups. Some of the original content of the oath survived though, namely content including prohibitions on abortion and euthanasia. As it is with such documents, no reason for this is given, beyond the exhortation on doctors not to provide such services to patients.

Of course, the oath really was a reflection of particular values held by a smallish cult in Greece a very long time ago. Why in today’s day and age medical doctors who are not Pythagorean (i.e. pretty much all of them) should abide by such values is unclear. This is particularly true for Christian students, if the history of battles between Christians and Pythagoreans is true, where reportedly Christians eventually burned the Pythagorean temple to the ground and destroyed the cult for good. It is also unclear why students who wish to practice medicine should have to take any such oaths to begin with.

A colleague of mine who teaches in a medical school introduced to his students a whole range of competing ethics codes for medical graduates and then asked them to pick the one they would be most comfortable taking their oath on. Not unexpectedly the whole gamut of ethical convictions unfolded. The students in that particular medical school hailed from all corners of the world, and so were the choice of oath they picked. At least they believed that there is value in taking such oaths to begin with. It’s probably a traditional thing. Today these oaths are frequently used by medical doctors to pick and choose ‘traditions’ they like and traditions they dislike. Surgery they might do, abortion – not so much, you get the drift. The randomness of it all is reason for concern, because their decisions are not actually derived from their traditional oath, but from other value systems that are then projected into the bits and pieces of the oath that are wheeled out to ‘justify’ this, such as the stance on abortion, euthanasia, IVF and any number of other ethically controversial medical issues. It turns out tradition isn’t even a justification for anything.

Exactly the same phenomenon crops up in debates on marriage equality. There is even a Facebook group ‘1,000,000 for traditional marriage’ which garnered support from less than 50,000 people worldwide. Traditionally marriage was a one-man-one-woman thing, ergo, so goes the argument, this is how it should be like today. Well, it doesn’t take much to realise that there is no ergo justifiable here either. Nothing follows at all from the fact that we do certain things today, or from the fact that we did certain things in certain ways in the past, for how we should do things from today onward. The point I am making here is that arguments from tradition have zero substance as arguments. They are non-arguments. Each time someone tells you that you should do a certain thing because of tradition, it’s best to tell them to go away and get a life. They merely describe what we have always done or what we have done over extensive periods of our history. If that was sufficient, we could justify slavery. After all, if we bought and sold other people for such a long time, surely it’s a tradition of sorts. The fact that there was such a tradition doesn’t provide us with any moral guidance with regard to what we should do in the future.

Now, to be fair, conservative thinkers like Edmund Burke pointed out why traditions might be valuable. He claimed that traditions provide societal stability and security. Clearly there is some usefulness in societal stability and security. That argument then isn’t any longer about whether there is a good reason to keep some tradition going. That argument simply warns us of ominous consequences if we don’t keep traditions going. The truth is, of course, that even conservatives need societal progress to occur, lest their societies would otherwise be frozen in time, eventually losing out to more agile competitors on the global stage. So they are back to square one so to speak. Even they need reasons to justify particular traditions if someone clamours for particular changes to how society goes about doing business, or how doctors go about doing medicine, etc. Unless there is a good reason beyond the fact that something is a tradition we should probably be prepared to abandon traditions more frequently if we are given good reasons for doing so.

Saturday, December 07, 2013

One of the privileges that comes with being an academic is that one is comparably mobile, the world really is one’s job oyster.
I chose to work between 2000 and 2005 in a medical school in Johannesburg, South Africa. Sub-saharan Africa at the time was the world’s region worst hit by HIV and AIDS. At a time when HIV infected people in the West got used to the idea of living to old age, people around me literally were dropping like flies. Talk about culture shock! In the condo-complex where I lived, several of our staff members died preventable AIDS-related deaths. One of my staff member’s life-partner died from AIDS, too. He had just matriculated from college.

Many of our students were infected and discussions began in the university whether we had a responsibility to sponsor medical insurance to ensure their survival while they were enrolled with us. To the outsider this might look like an issue best understood as people in the developing world being unable to afford access to life-preserving medication. And, to be fair, the price tags of essential medicines in many developing countries remain unacceptably high. However, this is not what actually caused in excess of 360,000 entirely preventable HIV-related deaths in South Africa.
The country’s president at the time, Thabo Mbeki, and his health minister, Manto Tshabalala-Msimang subscribed to wild conspiracy theories involving Western agencies wanting to crush African people’s aspirations. In their paranoid world AIDS medicines were a means to poison Africans. HIV was not the cause of AIDS, and AIDS didn’t quite exist as a new disease. They duly found a high-profile, ironically white, United States academic and a few of his, ironically white, allies to confirm their worst fears. Being the country’s president, Mbeki quickly set up a presidential expert panel involving mainstream scientists and a bunch of denialists. A funny idea to create a sparring match between discredited academics and mainstream academics and encourage them to entertain your paranoia. Mbeki clearly thought that a scientific consensus is reached not by evidence but by discussion and some kind of compromise (as if HIV could cause AIDS just a little bit, depending on the compromise reached).

Well, Mbeki and his side-kick Tshabalala-Msimang enforced policies aimed at keeping as many impoverished South African AIDS patients away from life-preserving medicines as was possible. HIV infected pregnant women were not given access to medicines proven to drastically reduce the risk for their newborns to be HIV infected. Thousands and thousands of HIV infected newborns came into this world as a result of these crazy policies. A Harvard University study estimated that in excess of 360,000 South Africans died preventable AIDS deaths during Mbeki’s reign. Some of the medical doctors in public sector hospitals who prescribed and provided AIDS drugs to their infected patients were disciplined by hospital managers carrying out the health minister’s orders.
Ask yourself how the world would have responded if such genocidal policies had been implemented by the apartheid regime preceding the ANC government that’s running the country today. No doubt international bodies would have busily prepared genocide charges. No doubt international campaigns would have got off the ground blaming the racist government for the preventable deaths of such a large number of South Africans. A black politician with liberation credentials presiding over what could demonstrably be described as genocide barely led to people batting their eyelids. Human lives clearly remain cheaper even today in that part of the world than elsewhere. Another, even crazier, head of state, Gambia’s president Yahya Jammeh insists that a herbal concoction he invented cures AIDS. Foreign aid workers disbelieving the story end up being kicked out of the country, and any Gambian criticizing his take on this medical problem end up in jail. Meanwhile Jammeh instructed HIV infected people to stop taking AIDS drugs.

What bothers me greatly is that government policies leading demonstrably to large numbers of preventable deaths remain unpunished. It is one thing if Mbeki had said that his government decided not to provide AIDS drugs due to their high cost. If you don’t have the resources to treat everyone it is fair game to allocate resources. But denying access to life-preserving medicine to large numbers of impoverished South African public sector patients because of truly crazy ideas about Western conspiracies is surely something else. Yet Mbeki walked away, enjoying today his generous retirement pay-out. His alcohol guzzling health ministerial side-kick died eventually of liver cirrhosis. Even there she remained true to her unethical form by jumping the queue toward a donor liver.

Well, enough on AIDS. This week United States talk show host Katie Couric used her show on national TV to peddle nonsense about the HPV vaccine. In Mbeki style she juxtaposed scientific mainstream views with anecdotes supplied by vaccine critics. The impression created was that there is a genuine debate, that there are genuinely two sides to this vaccine, when patently there are no two sides. While some of the stories presented were genuine human interest stories, they showed nothing relevant at all with regard to the safety and efficacy of this vaccine. It was clearly irresponsible of Couric to give a high-profile stage to quacks promoting their anti-science agendas. Almost certainly as a result of her action people who would clinically benefit from getting vaccinated won’t get vaccinated. Some of these women will eventually go on to develop cervical cancer. Is it acceptable, for the sake of ratings to promote quacks’ views on national television? I doubt it.

To be fair, Couric’s case is different to Mbeki’s actions. Women choosing not to get vaccinated did it on bad information they received through her TV show. Arguably women making such important health care choices would do better than to listen to anecdotes on a talk show when making important health care related choices affecting themselves. Let the buyer beware, as the old Romans said. On the other hand, the impoverished HIV infected South Africans depended on the national health care system to deliver life-preserving medicines. They did not have the luxury of choice to begin with. So, while the blame for bad choices in Couric’s cases arguably should be shared between those who act on anecdotes heard on her talk show and those who produced the show, the blame in South Africa falls squarely on Mr. Mbeki’s shoulders. Remarkably until today he was neither prosecuted nor did he ever utter an apology for the genocidal policies he presided over.